VOL. II.

ORIGINAL ARTICLES.

ENTEROPTOSIS.

BY PROF. E. MEINERT, M. D., Dresden, Germany.

(Concluded.)

THE examination of the solid abdominal viscera, to which we must now turn our attention, is made in accordance with rules which are generally acknowledged. I will only mention, in regard to the pancreas, that this gland, normally situated behind the stomach, is in cases of gastroptosis no longer covered by the stomach, and may be palpated as a cord which runs transversely across the vertebral column. Glenard's transverse cord of the colon depends upon a change in the position of the abdominal viscera which renders the pancreas palpable. I shall present, together with the results of experiments which I have made with living persons, those which I have gathered upon the dissecting table. The number of published dissections in cases of enteroptosis is remarkably small. According to Ewald, there were, up to 1890, only four cases. Since then, another case has been added by Kreg (14).

Anatomists are familiar with mal-position of the abdominal viscera, and attach special importance to the frequency of the vertical stomach and the sunken transverse colon in women, but they appear never to have observed the simultaneous existence of the prolapse of other abdominal organs. Virchow (25) only mentions the discovery of the simultaneous dislocation of the stomach and of the transverse colon.

The frequency with which enteroptosis appears, naturally leads to the question Why has the disease been so long overlooked on the dissecting table? I would

NO. 10.

like to mention, first, as a cause of this oversight, the general practice of dissecting the stomach and the intestines last. The original site of these organs is thus disturbed, in consequence of the preceding examination of all the other organs. To determine and record the position of these organs immediately after opening the abdominal cavity, is considered a useless method, because we have been accustomed to look upon these deviations from the natural order as incidents without any clinical importance. Finally, the physician whose attention has been directed toward these matters, is troubled in making his post-mortem diagnosis, on account of post-mortem changes, which may be so great as entirely to obliterate the conditions recognized during life. (Compare Fig. 4, preceding article, with Figs. 8 and 9.)

In the small number of cases which I have had an opportunity to examine after death and in which I had, during life, clearly established the presence of enteroptosis, I have obtained the following results: First, the diagnosis of enteroptosis may be positively made during life by the methods of investigation which have been pointed out, and is always confirmed by the autopsy. The position of individ ual organs in the living person suffering from enteroptosis may be found quite different in a corpse, as might be expected, from observations made during life.

No clinical or anatomical researches and experiments have, as yet, fully explained this. The imperfection of clinical researches consists essentially in a defective method of performing the autopsy, while the anatomical examination of a case of enteroptosis not clinically diagnosticated, may lead to an incorrect understanding, or to a total overlooking of certain displacements which have existed during life. The clinical examination is therefore the more valuable.

Among the organs which can only be recognized fully in the cadaver, the intestine must be placed first. Examination of the patient during life gives us a somewhat correct picture only, of course, of some portions of the colon. One portion of the small intestine can be seen only in the cadaver. On the other hand, we obtain a more correct picture of the form and position of the stomach, and of the position of the right kidney and the uterus, by careful and repeated examinations of living bodies. The stomach in the cadaver appeared more or less shrunken, in some cases more than would seem possible. The pylorus, espe

gynecologists. The loosely attached. kidney of the anatomists is identical with the movable kidney of the clinical physician.

The same difference of opinion recently existed between anatomists and gynecologists concerning the position and form of the uterus (26). The anatomists considered retroversion of the uterus as the normal position, because it was generally observed in cadavers; but we now know, and anatomists have acknowledged their former mistake, that the uterus of the living woman lies normally in anteversion, and bends backward only after death, if not held back by lesions.

cially, expands very much after the reception of food, and again is sometimes reduced to the thickness of the thumb.

The well-known picture of the long, sausage-like stomach may be considered a pathognomonic post-mortem form of enteroptosis. (Figs. 8, b, and 24.) Still there are stomachs which remain distended, even after death. A stomach which in life is usually directed downward and to the right, is in death often entirely normal. (Fig. 7, b.) The kidney, even if dislocated to a marked extent, slips back after death into its original "nest." From this fact originates the assertion of some anatomists, that a floating kidney is a rare occurrence, contradicting the frequency with which it is found by many physicians, especially by

In the post-mortem diagnosis of enteroptosis, the determination of the position of the stomach must be made very carefully, and still more carefully that of the kidneys, while the finding of the uterus in a retroverted or retroflexed condition furnishes no information concerning its position during life. The comparative condition in which the cadaver was found in Figs. 7, a, and 7, b, I call special attention to, because it seems to express best the existing type found in more than one hundred of my post-mortem cases. I add two other similar discoveries made in dissection as proofs, relating to the possible causes of these marked differences.

In Fig. 7, b, the stomach is found completely vertical, and is shrunken in all its diameters. This fact shows, at the

man 69 years of age whom I examined July 8, 1892, and found suffering from emphysema and cardialgia. Ascites developed more recently, and on Oct. 2, 1892, five liters of fluid were withdrawn by aspiration. The patient died Nov. 10, 1892, and Fig. 9, b and c, present the interesting facts found after death. The case was one of carcinosis of the peritoneum produced from cancerous tumors growing on the posterior walls of the stomach. In this case it was noticeable that the transverse colon, formerly lying in the hypogastrium, was, by the ascites, elevated to the upper part of the abdominal cavity, and becoming ad

ciency and passive congestion of the liver. He afterward became melancholy, and after wandering about for some days without taking food, died in consequence of a heat stroke. The autopsy showed the liver, which four months before had been enlarged to the navel, to be of normal size, and the right flexure of the colon, which had formerly been pressed down, in its normal position. The most striking changes are those which appear after death, and perhaps even during the last days of life, in case of stomachs which, when distended in life, reach nearly to the symphysis.

Fig 9, a, represents the condition of a

herent, did not sink down again after the fluid was removed. More marked still was the elevation of the stomach (Fig. 9, b). The force of the upward pressure was so great as to produce a retroflexion of that portion of the stomach which impinged against the diaphragm.

The observations which I have made concerning Glenard's views relating to the prolapse of the abdominal viscera in over five hundred living persons, and more than one hundred post-mortem examinations, may be summarized as follows:

Displacement of the abdominal viscera, a point to which I shall again revert, is

very frequent in women, and less frequent in men.

Every organ below the diaphragm, and even the diaphragm itself, may be involved. The part most frequently involved is the colon, next the stomach, then the kidneys, and last the uterus. The liver is very seldom prolapsed, and the spleen still less frequently. In relation to the small intestine, I can give no particular facts. The colon alone may be prolapsed; this occurs quite frequently. The same is true of the kidney, though seldom; also of the uterus, and most likely also of the spleen. The prolapse exists in all degrees, and there

of the cases, this portion of the intestine maintains its normal position. The left flexure of the colon, which can be examined only in cadavers, showed depression in only thirteen of my dissections. (Figs. 19, 21, and 29.) Still less can I conceive that, as Glenard believes he has discovered, the transverse colon decreases constantly from right below to left above, as in Fig. 15. In 38 per cent of the cases dissected by me, this portion of the colon had the form of a more or less depressed loop, but in the other 62 per cent, the cases do not correspond at all to Glenard's type. In 60 per cent of my observations upon living pers ons, I could

is no positive boundary between the normal and the abnormal. In case a single abdominal organ is found prolapsed, we are able to establish the displacement in most cases. These cases may be unhesitatingly pronounced pathological. To this class belong especially cases in which gastroptosis and coloptosis occur coincidentally. This is not to be doubted, because these cases are generally found in full-grown persons, and always in a marked degree, but very seldom in the early stages of development. Glenard's theory concerning the depression, without exception, of the right flexure of the colon, we beg leave to correct, as we have found that in only about two thirds

Fles

Fig. 9 c. (Post mortem.)

determine with certainty the depression of the pylorus (the liver we are sometimes unable to recognize), but I was convinced that in cadavers the pylorus is dislocated in 93 per cent of the cases. This dislocation may extend as low as the promontory, and even lower. (Fig. 23.)

The question how frequently gastrectasis may be found in connection with enteroptosis, cannot be answered in numbers, because neither the volume of the stomach nor the boundary between normal and enlarged volume can be actually determined; but in case two or three liters of carbolic acid gas can be developed suddenly in the stomach without creating pain, we may take it for granted.